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77 year old male daily wage labourer by occupation president of narayanapuram complaints of abdominal dtension since 3 days
History of presenting illness:
Patient was apparently a symptomatic until 3 days ago then he had complaints of sudden on set of abdominal distention accompined with twisting type of pain; Dyspnea, constipation decreased urine output, painful defecation aggravated after having food
No complaints of fever headache giddiness
No complaints of bilateral pedal edema no complaints of burning micturition
History of past illness
History of analgesic abuse for knee pain
History of empyema and on ATT 15 years ago
Outside USG:
1. Liver altered parenchymal ecotextur
2. Cholecystitis
3. Bilateral grade 2 rpd changes with renal cortical cysts
4. Moderate ascites
PERSONAL HISTORY:
- Diet - mixed
- Appetite- normal
- Sleep - normal
- Bowel - regular
- Bladder - decreased output and burning micturition
- Allergies- none
- Addictions- Beedi 4/ day
- Toddy/ every 3 days
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Vitals :
Temperature- afebrile
Respiratory rate - 16cpm
Pulse rate - 74 bpm
BP - 120/80 mm Hg.
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard.
Abdominal examination:
INSPECTION :
Shape of abdomen- distended
- Umblicus - normal
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny;
- No scars, sinuses. distended veins present
PALPATION :
Local rise of temperature present.
Tenderness present in RT hypochondriac region
Tense abdomen
Guarding absent
Rigidity absent
Fluid thrill not felt
Liver not palpable
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Fluid thrill: not felt
Shifting dullness: present
Tympanic note is heard on the midline and dull note is heard on the flanks in supine position
AUSCULTATION:
Bowel sounds are decreased
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
INVESTIGATIONS:
Serology:
HIV - negative
HCV - negative
HBsAg - negative
Treatment :
1. IV fluids Ns@ 50 ml/hr
2. T DOLO 650 MG / PO/TID
Date:5/3/23
AMC bed no.2
Day 3
S:diffuse pain in hypogastric region( decreases compared to yesterday) stools not passed
O:
O/e patient is c/c/c
Bp-110/90mmhg
Pr-72 pbm
Rr-20cpm
Temp-99F
GRBS - 111 mg/dl
B.Wt - 46 kgs
Abd girth - 76.5 cm
I/O : 1500/750 ml
CVS-s1s2+
RS-BAE+
CNS-NAD
P/A-soft , tender, Bowel sounds heard
SAAG:-0.8
Sr albumin-2.6
Ascitic albumin-1.8
Ascitic :-
amylase-7.59(normal 25-140)
Sugar-106(normal60-100)
Protien-3.5(normal<2.5)
LDH-180.7(normal 230-460)
Ascitic cell count
Provisional-2400
DLC awaited
Therapeutic Ascitic Tap done on 5/3/23 350 ml of ascitic fluid was drained
Date:6/3/23
AMC bed no.2
Day 4
S:diffuse pain in hypogastric region( decreases compared to yesterday) stools not passed
O:
O/e patient is c/c/c
Bp-110/90mmhg
Pr-72 pbm
Rr-20cpm
Temp-99F
GRBS - 111 mg/dl
B.Wt - 46 kgs
Abd girth - 76.5 cm
I/O : 1500/750 ml
CVS-s1s2+
RS-BAE+
CNS-NAD
P/A-soft , tender, Bowel sounds heard
HB: 11.1 TO 9.8
TLC : 9800 TO 8700
PLT: 3.82 TO 3.51
RBC : 3.97 TO 3.48
UREA : 55 TO 114
CREAT : 1.2 TO 1.2
NA+ : 139 TO 137 TO 140
K+ : 4.3 TO 4.1 TO 3.9
CL- : 99 TO 100 TO 101
IONIZED CA : 1.104 TO 1.05
P:
1. IV fluids Ns@ 75ml/hr
2.T DOLO 650 MG / PO/sos
Date:7/3/23
AMC bed no.2
Day 4
S: Stools passed, abdominal pain present(pain aggravated after eating idly), No fever spikes
O:
O/e patient is c/c/c
Bp-110/80mmhg
Pr-78 pbm
Rr-17cpm
Temp-99F
GRBS - 106mg/dl
B.Wt - 46 kgs
Abd girth - 71.5 cm
I/O : 1500/700 ml
CVS-s1s2+
RS-BAE+
CNS-NFND
P/A-soft , tender, Bowel sounds heard
HB: 11.1 ---> 9.8 ----> 9.2
TLC : 9800 ----> 8700 ---->8800
PLT: 3.82 ----> 3.51 ---->3.48
RBC : 3.97 ----> 3.48 ----> 3.28
UREA : 55----> 114----> 99----> 85
CREAT : 1.2----> 1.2----> 1.2----> 1.1
NA+ : 139----> 137----> 140----> 137
K+ : 4.3----> 4.1 ----> 3.9----> 3.6
CL- : 99 ----> 100----> 101----> 98
IONIZED CA : 1.03----> 1.05----> 1.0
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